PRO/CON: Why #FOAMed is NOT Essential to EM Education

What’s not to like about FOAM? You certainly can’t beat the price. It’s as ubiquitous and portable as your laptop or phone. And many of the contributors are leaders in our field – not simply knowledgable, but also exceptional communicators.

What’s not to like about FOAM? You certainly can’t beat the price. It’s as ubiquitous and portable as your laptop or phone. And many of the contributors are leaders in our field – not simply knowledgable, but also exceptional communicators.

I’m an enthusiastic supporter of FOAM. I use it, and I recommend podcasts, blogs and twitter feeds to my colleagues. In fact, back before there was an acronym for it, I started a journal club blog, to make complex discussions about EM research quickly accessible. And I led SAEM’s first social media committee, encouraging the use of social media at conferences and in promoting education.

But while FOAM has many great applications, I have noticed the enthusiasm of many supporters of FOAM goes too far. FOAM is so appealing, so engrossing, it’s easy to get carried away. And when that happens, the forms of learning you used to rely on are devalued, and eventually disregarded. When this happens to an experienced emergency physician, critical faculties erode and one’s practice narrows. When this happens to students and trainees, it can be disastrous.

It starts innocuously enough. You download a podcast and listen to it on your commute. You get access to cutting-edge commentary on the latest evidence, delivered with skill and insight. You learn something new, and maybe find yourself wishing your commute could be a bit longer.

A few days later, a journal arrives at your doorstep, thick and heavy. There are dozens of articles on a variety of topics, and as you skim the capsule summaries, you see something that was mentioned in that podcast you just heard. You remember the speaker’s voice – he dismissed this study’s findings but you can’t quite remember why. Maybe there will be a good letter-to-the-editor about this topic in a few months. But you recall the FOAM’s take-home message and reflect that you’re lucky to have an expert reviewing and summarizing the literature for you, as it comes out. You think maybe some day, years from now, that wisdom will find its way into EM textbooks – but those textbooks will still be obsolete, because of all the new practice-changing advice that’ll be shared over FOAM channels.

And just like that, you’ve made the leap. If peer review and published commentary on journal articles takes too long, and textbooks are hopelessly out-of-date, that just means FOAM is all the more important. It’s lucky that FOAM is so essential, because it’s also fun and engaging in a way that traditional learning never was.

So let’s knock FOAM a bit off its pedestal, and point out the many problems supporters overlook:

First, the quality is uneven. If you ever try to transcribe the salient points of a podcast, you very well may find yourself, ten or twenty minutes later, staring at a few bullet points. For every talented podcaster who’s speaking on a topic they know well, there’s at least one other who’ll consume your time with anecdotes or unnecessary deliberations. I find myself wishing I could just skim a transcript, or better yet, dispense with the podcast altogether and jump into the article or chapter the speaker is talking about.

Then there are the Twitter “debates” that are so tortuous to follow. Strangers wade in and out of the conversation; you’ve got to piece together who’s who, who said what, and where those supporting web links go. You’ve got to filter out the extraneous comments and asides, and unpack the abbreviations and conventions borne out of Twitter’s 140-character limit. It’s no wonder Twitter growth has leveled off, and published analyses suggest less than 2% of EM physicians are on Twitter. Sure, once you get the hang of it, Twitter can be amusing and occasionally enlightening, and you can interact with some smart people, but if your priority is to learn EM, you’ll probably save time just going to the primary source.

Then there’s the problems inherent in delivering FOAM. It turns out we don’t retain information as well when we’re commuting or listening on the go, compared to when we’re sitting in a lecture or focused on studying (see Zanussi 2012).

FOAM is also difficult to reference on shift. Lest you call me a luddite, I carry a tablet with me on the job, full of documents and references that inform my decision-making. Whatever I don’t have, I can usually look up pretty quickly. But I’m dismayed by how many academic conversations fall apart with “I think I heard it on a podcast a while back” or “we had an exchange over Twitter.” Twitter’s search function is notoriously unreliable, and in the ED, no one’s going to be able to cue up a podcast and fast-forward to the relevant part of a discussion. In an increasingly digital and mobile world, FOAM has somehow found a way to make academic content effectively inaccessible.

But my essential critique of FOAM is that it’s not a curriculum. This ought to be OK – there’s nothing wrong with absorbing information from an enthusiastic, knowledgeable communicator. But a trainee’s time is finite, and every hour spent listening to podcasts or parsing tweets is an hour where a textbook chapter wasn’t studied, a journal article wasn’t scrutinized. A few hours of FOAM certainly isn’t harmful, and minute-for-minute, retention may even be better than with traditional learning. But taken over weeks, months or years, the FOAM effect means you eventually have EPs with significant holes in the fundamentals of emergency medicine. You have students that can speak intelligently about the latest in hypothermia research, but don’t know how to work up shoulder pain. You have residents who’ve heard that a viral pneumonia can be indistinguishable from bacterial on X-ray, but not that you’d better give antibiotics anyway. The expert commentary that FOAM provides can be woefully misapplied in the hands of someone who doesn’t yet know the standard of care.

Even experienced physicians can run the risk of overdosing on FOAM. I’ve seen it a bit in myself and my colleagues. When we go too long without picking up a journal or textbook, but convince ourselves that we don’t need that old-fashioned stuff to be on the cutting edge, we lose the critical faculties and broad understanding of EM that took us years to cultivate.

So if you’re already a pro and looking to develop a niche in EM, FOAM is a good way to get up to speed. You’ll hear from, and maybe interact with, leaders in the specialty. It’s fun, educational and easy. But you can still be an excellent physician without FOAM, and you can’t be an excellent physician subsisting on FOAM alone. It’s no substitute for the real thing, it’s no alternative curriculum, and in the end, FOAM simply isn’t an essential part of EM education.

Nicholas Genes, MD, PhD, an editor at EPM and MedGadget.com, was an early emergency physician blogger with his blog ‘Blogborygmi’.

What is FOAM?

In 2012, Mike Cadogan conceived of FOAM – Free Open Access Meducation – over a pint of Guinness in Dublin. Cadogan, one of the emergency physician technophiles behind the Australian “Life in the Fast Lane” blog, had observed first-hand the meteoric rise in the use of social media, blogs and podcasts in emergency medicine education. (His own blog currently catalogs 279 such online resources.) Cadogan also noted that in the broader universe of medical education, these resources were getting lumped together as “social media” which, to Cadogan’s mind, gave them short shrift. A new term was in order, out of which was birthed a community, even an educational movement.

These days it’s hard to find a credible emergency physician Twitter account that doesn’t give at least a passing reference to FOAM. In fact, many mention the hashtag #FOAM right in their Twitter description. Why? Because this term has galvanized a community of online educators who believe in the free – and rapid – dissemination of medical information.

As the name suggests, FOAM resources are free and predominantly social media based, including podcasts, tweets, blogs, video, photographs, web-based applications, Facebook groups and Google hangouts. Accessibility is key: by being web-based these resources are available to any and all providers, from Malaysia to Madagascar to Minnesota.

The content of FOAM is as varied as the bloggers and tweeters who create it, but its strength appears to be encouraging open debate of hot topics and keeping readers up to date with rapidly emerging trends. Students have embraced the community as a low-barrier way to enter the medical conversation. Universities have seen FOAM resources as a convenient – and cost-effective – way to augment traditional learning and “flip the classroom.”

Defining a digital movement that is based on the principle of open access is a bit like trying to nail jello to a wall, but the proof of the pudding is in the tasting. There is no doubt that FOAM is changing the way emergency physicians learn and is spurring on a new level of global dialogue.

Really enjoyed this pro/con debate about FOAMed. Being skeptical of this social media education tool is important. Like all tools it is how you use them rather than the tool themselves. Everything in moderation. Ken

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